Real situation from a metro city in India. Query in CME INDIA …

Two brothers aged 66 and 68 years, who stay in the same house and in the same room turned out COVID Positive on 2 different dates [as per the test reports], within a span of 3 to 4 days.

1. Can both brothers be quarantined in the same room? If yes, what are the precautions to be taken?
2. Their two sisters also live in the same house, a 3-bedroom house with attached bathrooms. They are the care givers. What are the precautions for them – apart from masking, and distancing.

Brief history:

• Both brothers have not left the house ever since the 1st lockdown started in March 2020.
• Younger brother got fever on and around 14^th August and was managed on antibiotic Azithromycin for 3 days and the fever subsided.
• Older brother developed fever on and around 17th August. Slight cough and no shortness of breath. He was also put on Azithral for 5 days. On 22nd August – Day 6, he had headache and on 23rd August – Day 7, he developed shortness of breath.
• RT-PCR and antibody testing were done on 23^rd.On the same day, HR CT Chest was also done – CT Chest showed signs of Corad-4.
• He was hospitalised on 23rd August, put on Inj. Remedesvir and another supportive regimen. His condition improved and was discharged on 27^th with a stable condition.
• In the meantime, another brother got her RT-PCR done on 25th and he reported positive on 26^th. Since he was asymptomatic now, he started home quarantine package with another hospital. Quarantined at Home from 27th morning.
• As on 29th August, younger brother is on Day 4 of home quarantine and the older brother was on Day 3 after discharge. Both quarantined in the same room.

Answer by Dr Hem Shankar Sharma, Assoc prof. of Medicine and Nodal officer, Bhagalpur:

• Yes, they can be quarantined in the same room. Standard precautions, of Masking should be used, with keeping the sanitization level up, particularly, using the commode in washroom. As both have contracted, Covid in a short span, not moving out, then contact tracing must be done, to understand the source.
• Other two caregivers should be investigated with RTPCR, as the time duration is more than a week, in which, if contracted, will show the positive result !!, The care givers should strictly follow distancing, the best is obstructing the doorways by keeping a table on which foods etc, are served, duly sanitized. N95 or a surgical mask should be used by both positive and care givers.
• Standard follow up of caregivers, for any symptoms, which are varied, and SpO2 evaluated. No specific treatment for the caregivers.
• As the first brother showed CORAD 4, he must be followed, with CBC, D DIMER, CRP, IL 6 levels. A check XRAY CHEST is also needed in a week time, at least. Strict follow up for post Covid evaluation should not be forgotten!

Query: Do you think prophylactic dexamethasone be started to sisters if tests positive?

Answer by Dr N K Singh:

No, not at all. Not a single trial supports it. But it is felt that at GP level, it is being done. As per personal communications, I am aware that if fever is persisting for 4 to 5 days, people are starting it. This is what village practioners were doing for decades! This is a wrong trend. I do feel it is high time to do a case-control study in use of steroids in mild to moderate cases, although there is no background science. It is just to know benefits and harms, as it is in practice off label.

Learning Points from the latest research, published online on 2nd September 2020

• Administration of systemic corticosteroids, compared with usual care or placebo, was associated with lower 28-day all-cause mortality in critically ill patients with COVID-19.
• In this prospective meta-analysis of 7 randomized clinical trials that included 1703 critically ill patients with COVID-19 recruited from countries on 5 continents, administration of corticosteroids was associated with lower all-cause mortality at 28 days after randomization. There was no suggestion of an increased risk of serious of adverse events.
• The ORs for the association between corticosteroids and mortality were similar for dexamethasone and hydrocortisone.
• The comparison of the association between low-dose corticosteroids and mortality and the association between high-dose corticosteroids and mortality was imprecisely estimated.
• The optimal dose and duration of treatment could not be assessed in this analysis, but there was no evidence suggesting that a higher dose of corticosteroids was associated with greater benefit than a lower dose of corticosteroids.
• The findings from this prospective meta-analysis provide evidence that treatment with corticosteroids is associated with reduced mortality for critically ill patients with COVID-19.
• The findings contrast with outcomes reported for the administration of corticosteroids among patients with influenza, for whom mortality and hospital-acquired infections may be increased by the administration of corticosteroids

[Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19A Meta-Analysis The WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group JAMA. Published online September 2, 2020. doi:10.1001/jama.2020.17023)]

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